Method and apparatus for forming a self-locking adjustable loop

ABSTRACT

A self-locking adjustable loop construction and a method of forming the construction are disclosed. The construction can include a flexible member having a first end, a second end and a first portion therebetween. The first end can be passed back through the first portion at a first point such that the first end passes through the first portion from a first side of the flexible member to a second opposite side of the flexible member. The first end can be passed through the first portion at a second point spaced apart from the first point such that the first end passes through the first portion from the second side to the first side so as to place the second end outside of the first portion.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No. 13/098,897 filed on May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/702,067 filed on Feb. 8, 2010, which is a continuation of U.S. patent application Ser. No. 11/541,505 filed on Sep. 29, 2006 and is now U.S. Pat. No. 7,658,751 issued on Feb. 9, 2010.

This application is a continuation-in-part of U.S. patent application Ser. No. 12/719,337 filed on Mar. 8, 2010, which is a continuation-in-part of U.S. patent application Ser. No. 12/489,168 filed on Jun. 22, 2009, now U.S. Pat. No. 8,361,113 issued on Jan. 29, 2013, which is a continuation-in-part of U.S. patent application Ser. No. 12/474,802 filed on May 29, 2009, now U.S. Pat. No. 8,088,130 issued on Jan. 3, 2012, which is a continuation-in-part of (a) U.S. patent application Ser. No. 12/196,405 filed on Aug. 22, 2008, now U.S. Pat. No. 8,128,658 issued on Mar. 6, 2012; (b) U.S. patent application Ser. No. 12/196,407 filed on Aug. 22, 2008, now U.S. Pat. No. 8,137,382 issued on Mar. 20, 2012; (c) U.S. patent application Ser. No. 12/196,410 filed on Aug. 22, 2008, now U.S. Pat. No. 8,118,836 issued on Feb. 21, 2012; and (d) U.S. patent application Ser. No. 11/541,506 filed on Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009.

This application is a continuation-in-part of U.S. patent application Ser. No. 13/645,964 filed on Oct. 5, 2012, which is a divisional of U.S. patent application Ser. No. 12/570,854 filed on Sep. 30, 2009, now U.S. Pat. No. 8,303,604 issued on Nov. 6, 2012, which is a continuation-in-part of U.S. patent application Ser. No. 12/014,399 filed on Jan. 15, 2008, now U.S. Pat. No. 7,909,851 issued on Mar. 22, 2011.

This application is a continuation-in-part of U.S. patent application Ser. No. 13/098,927 filed May 2, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 12/196,398 filed Aug. 22, 2008, now U.S. Pat. No. 7,959,650 issued on Jun. 14, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 11/784,821 filed Apr. 10, 2007.

The disclosures of all of the above applications are incorporated by reference herein.

FIELD

The present disclosure relates generally to a method and apparatus for forming a self-locking adjustable loop.

BACKGROUND

The statements in this section merely provide background information related to the present disclosure and may not constitute prior art.

It is commonplace in arthroscopic procedures to employ sutures and anchors to secure soft tissues to bone. Despite their widespread use, several improvements in the use of sutures and suture anchors can still be made. For example, the procedure of tying knots can be very time consuming, thereby increasing the cost of the procedure and limiting the capacity of a surgeon. Furthermore, the strength of the repair may be limited by the strength of the knot. This latter drawback may be of particular significance if the knot is tied improperly as the strength of the knot in such situations can be significantly lower than the tensile strength of the suture material.

To overcome this problem, sutures having a single preformed loop have been provided. FIG. 1 represents a prior art suture construction. As shown, one end of the suture is passed through a passage defined in the suture itself. The application of tension to the ends of the suture pulls a portion of the suture through the passage, causing a loop formed in the suture to close. Unfortunately, relaxation of the system may allow a portion of the suture to translate back through the passage, thus potentially relieving some of the desired tension.

It is an object of the present teachings to provide an alternative arrangement for anchoring sutures to bone and soft tissue. The arrangement, which is relatively simple in design and structure, is highly effective for its intended purpose.

SUMMARY

This section provides a general summary of the disclosure, and is not a comprehensive disclosure of its full scope or all of its features.

According to one aspect, the present teachings provide a method of forming a self-locking adjustable loop. The method can include providing a flexible member having a first end, a second end and a first portion therebetween. The first end of the flexible member can be passed back through the first portion at a first point such that the first end passes through the first portion from a first side of the flexible member to a second opposite side of the flexible member. The first end can be passed through the first portion at a second point spaced apart from the first point such that the first end passes through the first portion from the second side to the first side so as to place the second end outside of the first portion.

According to another aspect, the present teachings provide a method of forming a self-locking adjustable loop. The method can include providing a flexible member having a first end, a second end, and a first portion therebetween, and forming the flexible member into a pleated configuration having a plurality of interconnected layers each extending a length of the flexible member and orientated in a stacked relationship relative to each other. The first end of the flexible member can be passed back through the first portion at a first point such that the first end passes through the first portion from a first side of the flexible member to a second opposite side in a direction other than parallel to a longitudinal axis of the first portion. The first end can be passed through the first portion at a second point such that the first end passes through the first portion from the second side to the first side in a direction other than parallel to the longitudinal axis the of the first portion so as to place the second end outside of the first portion, the second point being spaced longitudinally from the first point.

According to yet another aspect, the present teachings provide a self-locking adjustable loop construction including a flexible member having a first end, a second end, and a first portion between the first and second ends. The first end can be passed through the first portion at a first point from a first side to a second side in a direction other than parallel to a longitudinal axis of the first portion proximate the first point. The first end can be passed through the first portion to form a self-locking adjustable loop.

In still another aspect, the present teachings provide a self-locking adjustable loop construction including a flexible member having a first end, a second end, and first and second portions between the first and second ends. The second portion can be passed through the first portion at a first point from a first side to a second side in a direction other than parallel to a longitudinal axis of the first portion to form a self-locking adjustable loop.

Further areas of applicability will become apparent from the description provided herein. The description and specific examples in this summary are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure.

DRAWINGS

The present teachings will become more fully understood from the detailed description, the appended claims and the following drawings. The drawings are for illustrative purposes only and are not intended to limit the scope of the present disclosure.

FIG. 1 is a view of a prior art suture construction;

FIG. 2 is a view of an exemplary self-locking adjustable loop construction according to the present teachings;

FIG. 2A is a view of an exemplary formation of the adjustable loop construction of FIG. 2 according to the present teachings;

FIG. 3 is a view of an exemplary alternative construction of the self-locking adjustable loop construction of FIG. 2 having two loops according to the present teachings;

FIG. 3A is a view of an exemplary alternative construction of the self-locking adjustable loop construction of FIG. 3 according to the present teachings;

FIG. 3B is a view of another exemplary alternative construction of the self-locking adjustable loop construction of FIG. 3 according to the present teachings;

FIG. 4 is a view of an alternative construction of the self-locking adjustable loop construction of FIG. 3 according to the present teachings;

FIG. 5 is a view of an exemplary alternative self-locking adjustable loop construction according to the present teachings;

FIG. 5A is a view of an exemplary alternative self-locking adjustable loop construction of FIG. 5 having two loops according to the present teachings;

FIG. 5B is a view of an exemplary application of the self-locking adjustable loop construction of FIG. 5 depicting securing soft tissue to bone according to the present teachings;

FIG. 6 is a view of an exemplary alternative self-locking adjustable loop construction according to the present teachings;

FIG. 7 is a view of an exemplary apparatus for forming a self-locking adjustable loop construction according to the present teachings;

FIG. 8 is a view of the exemplary apparatus of FIG. 7 in an alternate position according to the present teachings;

FIG. 9 is a view of the exemplary apparatus of FIG. 7 coupled to a device according to the present teachings;

FIG. 10 is a view of an exemplary alternative self-locking adjustable loop construction according to the present teachings;

FIG. 11 is a view of an alternative construction of the adjustable loop construction of FIG. 10 having two loops according to the present teachings;

FIGS. 12A and 12B are views of an exemplary retention feature for the self-locking adjustable loop configurations according to the present teachings;

FIG. 13 is a view of an exemplary graft in a pre-formed state according to the present teachings; and

FIGS. 14A and 14B are views of an exemplary arrangement for forming the self-locking adjustable loop constructions of FIGS. 10 and 11 according to the present teachings.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is in no way intended to limit the present disclosure, its application, or uses. It should be understood that throughout the drawings, corresponding reference numerals indicate like or corresponding parts and features.

With reference to FIGS. 2 and 2A, an adjustable self-locking loop construction 10 is provided. The adjustable loop construction 10 can include a flexible member or suture 14 having a width or diameter in cross-section sufficient to pass a section of the suture 14 back therethrough, as will be described in greater detail below. Adjustable loop construction 10 can be formed with only a single or unitary suture 14 having a solid construction or alternatively a hollow core. The suture 14 can also include a braided structure, a ribbon structure or a monofilament structure.

Suture 14 can include a first end 18, a first portion 22 proximate the first end 18, a second end 26 and a second portion 30 proximate the second end 26, as generally shown in FIG. 2. The adjustable loop construction 10 can be constructed by forming an accordion or wave-like configuration 34 with the first portion 22 of suture 14. The accordion configuration 34 can include multiple legs 38 having connecting portions 42 on opposite ends of the legs, as shown in FIG. 2. Once the accordion configuration 34 is formed, the second end 26 of the suture 14 can be passed through an aperture formed in each leg 38 or pierced through each leg 38 such that an adjustable loop 46 is formed at one end 50 of the accordion configuration 34 and the second end 26 extends beyond a second end 54 of the accordion configuration 34, as shown in FIGS. 2 and 2A.

It should be appreciated that while the above discussion references the second end 26 being passed through the accordion region being formed with the first portion 22, the first end 18 could alternatively be passed through the accordion configuration 34, which could be formed with the second portion 30. It should also be appreciated that while FIG. 2 shows the second end 26 being passed through a central portion of the legs 38, the second end 26 could be passed through various positions of legs 38 along a longitudinal axis 58 thereof.

Continuing with the exemplary illustrations in FIGS. 2 and 2A, second end 26 can be passed through each leg 38 in a direction that is not parallel to the longitudinal axes 58. In an exemplary configuration, second end 26 can be passed through each leg 38 in a direction perpendicular or substantially perpendicular to longitudinal axis 58. It should be appreciated that while the legs 38 are shown in FIG. 2 as having an orientation substantially perpendicular to a longitudinal axis 62 of the second portion 30 as it is passed therethrough, the legs 38 can include other non-parallel orientations relative to axis 62, such as 45 degrees.

With the adjustable loop 46 being formed as shown in FIGS. 2 and 2A, tension can be applied to the second end 26 of suture 14 that extends from the second end 54 of the accordion configuration 34. Upon applying tension to second end 26, the size of loop 46 can be reduced to a desired size or load. At this point, additional tension from both the loop 46 and the tension being applied to second end 26 can cause the suture 14 to constrict and thereby reduce in diameter due to the axial tensile load being applied. In addition, the legs 38, by way of their non-parallel orientation to the second portion 30, can cause a transverse force to be applied to second portion 30 once tension is applied from the loop 46 and the second portion 30.

Such reduction in diameter can cause the legs 38 to squeeze or constrict around the portions of second portion 30 passing therethrough, which creates a mechanical interface between the interior portions or apertures of the legs 38 that are constricting around the portions of the second portion 30 passing therethrough. As a result, under tension, the mechanical interface along with the transverse force applied by each leg 38 can efficiently lock the second portion 30 to the accordion configuration 34 at a desired size of loop 46.

The accordion configuration 34 can include the plurality of legs 38, as discussed above. The number of the plurality of legs 38 utilized can affect the ability of the accordion configuration 34 to provide the self-locking capability discussed above. In this regard, it should be appreciated that providing more legs 38 in the non-parallel orientation to the second portion 30 passing therethrough can provide a greater locking capability of the adjustable self-locking construction 10. In addition, for a braided suture construct, the number of weaves as well as how tightly the weaves are formed can affect the number of legs 38 that can be required to form the self-locking adjustable loop construction 10. For example, more legs 38 can be required for a braided suture construct that includes less weaves and/or is more loosely braided than a suture construct having a tightly braided structure or monofilament.

With additional reference to FIGS. 3 and 4, an alternative self-locking adjustable loop construction 10A is provided that can include an additional loop 46′ thereby forming a bow tie configuration. Adjustable loop construction 10A can be formed and can function in a similar manner as adjustable loop construction 10, except two loops 46, 46′ can be provided and available for securing to bone, soft tissue, or other devices. More specifically, adjustable loop construction 10A can be formed by taking first end 18 and passing it back through the legs 38 of accordion configuration 34 in an opposite axial direction as second end 26 and portion 30 were passed through the accordion configuration 34, as discussed above with reference to FIGS. 2 and 2A.

With this construction, a portion 64 of suture 14 passed through accordion configuration 34 by first end 18 can be adjacent to second portion 30, as shown in FIG. 3. In one exemplary configuration, first end 18 and portion 64 can be passed through the same aperture or opening 66 created in legs 38 by second portion 30 being passed therethrough. Alternatively, and with reference to FIG. 4, first end 18 and portion 64 can be passed through legs 38 spaced apart from second portion 30 such that portion 64 and second portion 30 form separate openings 66, 66′ in legs 38.

In operation, tension can be applied to both the first and second ends 18, 26 until the corresponding loops 46, 46′ are reduced to the desired size and/or load. At this point, the tension applied by the loops and the respective ends can cause the diameter reduction and transverse forces discussed above thereby creating the mechanical interface and locking the loops 46, 46′ relative to the accordion configuration 34. In addition, with reference to the construction 10A shown in FIG. 3, the first and second portions can be contiguous to each other thereby causing additional friction and resistance to relative movement under tensile load.

With additional reference to FIGS. 3A and 3B, alternative adjustable loop constructions 10B and 10C are shown that are similar in operation to the constructions 10A of FIGS. 3 and 4, such that only differences between the constructions will be discussed below. With particular reference to construction 10B shown in FIG. 3A, the accordion configuration 34 can be separated into first and second portions 34A and 34B by an intermediate portion 34C. First end 18 can extend through separate openings 66′ in the plurality of legs 38 of the first accordion portion 34A to form adjustable loop 46′. Similarly, second end 26 can be passed through openings 66 of the plurality of legs 38 of the second accordion portion 34B to form adjustable loop 46. In this exemplary configuration, portions 30 and 64 can be configured to not overlap when passed through the respective accordion portions, as shown in FIG. 3A. It should be appreciated that while construction 10B has been discussed above as having an intermediate portion 34C, construction 10B could also be provided without the intermediate portion, similar to accordion configuration 34 shown in FIG. 3.

As shown in FIG. 3B, construction 10C includes an alternative loop construction to that of construction 10B shown in FIG. 3A, where loops 46, 46′ are formed so as to span the accordion configuration 34 instead of being formed at opposite ends of the accordion configuration 34. In this configuration, construction 10C can form a double loop configuration where the first and second loops 46 can each traverse a path from one end of the accordion configuration 34 to the other end of the accordion configuration 34, as shown in FIG. 3B.

Turning now to FIG. 5, an alternative self-locking adjustable loop construction 10D is shown that is similar to the construction 10 of FIG. 2, except formed with a flat braid or ribbon construct 74. Adjustable loop construction 10D can be formed in the same manner as construction 10, noting that the entry and exit points of the second end 26 being passed through construct 74 are the same except on opposite sides of the braid or ribbon. With additional reference to FIG. 5A, an alternative adjustable loop construction 10E is shown that is similar to construction 10D, except that an additional loop 47 is formed using second end 26 to form an alternative double loop configuration. As shown in FIG. 5A, second end 26 can be passed back through accordion configuration 34 in a direction opposite the direction used to form loop 46 so as to form second loop 47. Second end 26 can be passed back through as discussed above using the same openings in legs 38, or different openings like shown in FIG. 4.

With additional reference to FIG. 5B, an application of the adjustable loop construction 10D of FIG. 5A will now be discussed in connection with securing soft tissue 75 to a bone 76, such as a femur. In this exemplary application, soft tissue 75 can be looped around loop 46 of construction 10D and secured at its free or opposite ends (not shown). The first end 18 of construction 10D can be coupled to a fixation member such as the toggle anchor 77 illustrated. First end 18 can be passed into a bone tunnel 78 and secured relative to an end 79 of tunnel 78 opposite an end facilitating entrance of soft tissue 75 into tunnel 78, as shown in FIG. 5B. Second end 26 can also be passed through tunnel end 79 and tensioned to draw soft tissue 75 into tunnel 78 thereby tensioning and securing soft tissue 75 to bone 76.

By applying tension to second end 26, the size of loop 46 can be reduced to a desired size resulting in soft tissue 75 being tensioned, which results in a tensile force being applied to construction 10D by soft tissue 75 relative to secured end 18 and tensioned end 26. The tensile force can cause the suture 14 to constrict and thereby reduce in diameter due to the axial tensile load being applied. In addition, the legs 38 can squeeze or constrict around the portions of second portion 30 passing therethrough, which creates a mechanical interface between the interior portions or apertures of the legs 38 that are constricting around the portions of the second portion 30 passing therethrough. As a result, under tension, the mechanical interface along with the transverse force applied by each leg 38 can efficiently lock the second portion 30 to the accordion configuration 34 at a desired size of loop 46 and secure soft tissue 75 to bone 76.

With additional reference to FIG. 6, another alternative self-locking adjustable loop construction 80 is provided. Adjustable loop construction 80 can form an adjustable loop 82 by initially passing or piercing second end 26 through first portion 22 of suture 14 on a first side 84 thereof. Second end 26 can then exit first portion 22 at point or aperture 88 on a second side 94 thereof opposite the first side 84, noting that with respect to the view shown in FIG. 6, the first side 84 is not visible but is directly behind the visible second side 94. Second end 26 can then be wrapped partially around suture 14 to subsequently enter first portion 22 on first side 84 at a second point or aperture 98, opposite of the last exit point 88 on second side 94. The second end 26 can then exit first portion 22 at point or aperture 104 on second side 94. This pattern can continue for a desired number of times, with each successive partial wrap-around and pass-through of second end 26 relative to first portion 22 providing additional self-locking capability, as discussed below. It should be appreciated that the second end 26 can be partially wrapped around first portion 22 between an exit point and an entry point, such as apertures 88 and 98, by varying amounts including 180 degrees and/or 90 degrees.

Upon applying tension to first end 18 of suture 14, the size of loop 82 can be reduced to a desired size or load. At this point, tension can be applied to the first portion 22 of the suture 14 from both the loop side and the first end 18 such that the diameter of the first portion constricts or reduces in size. This reduction in diameter applies a constricting or squeezing force on the portions of suture 14 passing through the first portion 22 thereby locking these portions relative to the first portion 22 and thus the desired size of loop 82. In addition, the suture portions that are partially wrapped around the outside of first portion 22 can provide additional frictional engagement and resistance to movement once tensioned. In this regard, having the suture portions wrap around first portion 22 by an amount of 180 degrees, as shown in FIG. 6, provides for more surface area for more frictional engagement during tensioning.

It should be appreciated that while suture 14 is shown in FIG. 6 as having a generally round or non-flat shape in cross-section, other shapes can be used to form the self-locking adjustable loop construction 80, such as the flat ribbon or braid structure 74. While adjustable loop construction 80 has been shown with one loop 82, it should also be appreciated that construction 80 could include a double loop bow tie configuration that can be formed by passing first end 18 back through first portion 22 after the second end 26 has been passed through as described above. First end 18 can be passed back through in an opposite direction, but similar manner as second end 26.

With additional reference to FIGS. 7-9, an exemplary apparatus 120 that can be used for forming the self-locking adjustable loop constructions 10, 10A and 10B is shown. Apparatus 120 can include a die or similar structure 124 suitable for forming the accordion configuration 34 discussed above. Die 124 can include a first member 128 and a second member 132, as shown in FIG. 7. First member 128 can include a first plurality of fingers or projections 136 extending therefrom and spaced apart from each other by a first space or gap 140. Similarly, second member 132 can include a second plurality of projections 144 extending therefrom and spaced apart from each other by a second gap 148, as also shown in FIG. 7.

The first and second members 128, 132 can be configured to intermesh with each other such that second projections 144 are received in corresponding first gaps 140, as shown in FIG. 8. As there can be more first projections 136 than second projections 144, an interior subset 136A of the first projections 136 can be received in the corresponding spaces 148 while outer projections 136B can be received on an outer side of corresponding outer projections 144B of second projections 144, as shown in FIG. 8.

With particular reference to FIGS. 7 and 8, operation of the die 124 will be described in greater detail. A flexible member, such as suture 14 or ribbon 74, can be placed in a groove or track 156 in second member 132 so as to serve as a guide or locator for the respective suture placed therein. First member 128 can then be closed onto second member 132 such that the respective projections intermesh as described above and form the accordion pattern of the respective suture therebetween, as shown in FIG. 8 with reference to FIG. 2.

Once the members 128, 132 of die 124 are closed with a suture therebetween as described above, a needle or other suitable passing member 158 can be used to pass second end 26 through a slot 160 in each of the projections 136, 144 and pierce through legs 38 of the accordion configuration 34, as also shown in FIG. 8. Piercing the second end through legs 38 with passing member 158 can form apertures through each of the respective legs 38, as discussed herein. It should be appreciated that various different numbers of projections 136, 144 can be used, including more or less projections 136, 144 than shown in FIGS. 7-8 to arrive at an accordion configuration 34 with a desired number of legs 38. It should also be appreciated that while die 124 has been described as having groove 156 associated with second member 132 as well as second member 132 having less projections than first member 128, die 124 could be configured in an opposite manner where first member 128 include the groove as well as more fingers than second member 132.

With continuing reference to FIGS. 7-8 and additional reference to FIG. 9, die 124 can be in the form of a stand-alone configuration (as discussed above) for use on a base structure, such as an operating room table for intraoperatively forming the self-locking adjustable loop constructions 10,10A and 10B discussed above. Alternatively, first and second members 128, 132 can be formed on or attached to respective ends of a movement device, such as forceps 168 shown in FIG. 9. In this manner a surgeon, clinician or the like can easily manipulate the first and second members 128, 132 along with a respective suture to form the accordion configuration 34 and desired self-locking adjustable loop construction 10, 10A and 10B intraoperatively.

Turning now to FIGS. 10-14, an alternative self-locking adjustable loop construction 180 is shown, as well as an exemplary apparatus that can be used for forming construction 180. With particular reference to FIG. 10, adjustable loop construction 180 can be formed from a suture or graft 184. Graft 184 can be formed to include a plurality of layers 188 connected to each other in an accordion or pleated configuration 192 such that each of the layers 188 are parallel to or substantially parallel to each other in a compressed or flattened state of graft 184. In this regard, the discussion of adjustable loop construction 180 will continue with reference to using a graft 184 (shown in an exemplary non-pleated form in FIG. 13), while it should be understood that construction 180 could also be formed in the same manner from a suitable suture material. Graft 184 can be any graft suitable for forming the pleated configuration 192 discussed above, including a fascia late allograft or autograft.

In the exemplary configuration shown in FIG. 10, each layer 188 can have the same width 196 in a direction perpendicular to a longitudinal length of graft 184, as shown with reference to longitudinal axis 200. The plurality of layers 188 can include a top layer 188A, a lower or bottom layer 188B and one or more intermediate layers 188C therebetween. Each intermediate layer 188C can include an upper surface 204 and an opposite lower surface 208 and can be connected to a layer adjacent the upper surface 204 on a first side 212 and connected to a layer adjacent the lower surface 208 on a second opposite side 216, as shown in FIG. 10. In this manner, it should be appreciated that graft 184 is continuous from top layer 188A through intervening connected layers 188B to bottom layer 188C. Graft 184 can include a varying number of intermediate layers 188C as may be required to, for example, achieve a certain desired strength of graft 184.

Graft 184 can include a first end 224, a first portion 228 adjacent first end 224, and a second opposite end 232, as shown in FIG. 10. Adjustable loop construction 180 can be formed by passing second end 232 through first portion 228 in an alternating fashion forming a weave-like pattern 236 and a self-locking adjustable loop 238, as shown in FIG. 10. More particularly, second end 232 can be initially passed through each layer 188 of the pleated configuration 192 from a first side 240 of the first portion 228 and then be passed through each layer 188 of pleated configuration 192 from a second opposite side 244 of first portion 228 at a second point 248 axially spaced apart from the initial pass through point, as shown in FIG. 10.

Second end 232 can then be passed though first portion 228 at a third point 252 starting from the first side 240 and exiting on the second side 244, where the third point 252 is axially spaced apart from the second point in a direction away from the initial pass through point. The pattern 236 can continue with second end 232 being passed through first portion 228 at a fourth point 256 starting from the second side 244 and exiting on the first side 240, where the fourth point 256 is axially spaced apart from the third point 252 also in a direction away from the initial pass through point, as shown in FIG. 10. Second end 232 can be passed through first portion 228 at each of the first through fourth points in a direction other than parallel to longitudinal axis 200 of first portion 228, including a direction perpendicular or substantially perpendicular thereto.

In operation, the loop 238 can be adjusted by placing tension on second end 232 to move second end relative to first portion 228 thereby reducing the size of loop 238 to a desired size or load. At this point, tension can be applied on first portion 228 by loop 238 thereby causing a restriction in width 196. The restriction in width 196 can apply a squeezing or constricting force against the portions of graft 184 weaving through first portion 228 in a manner similar to discussed above. The constricting force combined with the alternative weave pattern can lock the loop at the desired size or load under tension relative to first portion 228.

With additional reference to FIG. 11, an alternative self-locking adjustable loop construction 180A is shown that can include an additional adjustable loop 238′ thereby forming a bow tie configuration. Adjustable loop construction 180A can be formed and can function in a similar manner as adjustable loop construction 180, except two loops 238, 238′ are provided and available for securing to bone, soft tissue, or other devices. More specifically, adjustable loop construction 180A can be formed by taking first end 224 and passing it back through the portion 228A of the graft 184 in this configuration having the weave pattern 236 described above. First end 224 can be passed through portion 228A in an opposite axial or longitudinal direction as second end 232 using the same pass through points 248-256 to mimic the weave pattern 236, where the portion of graft passed back though by the first end 224 can rest on top of weave pattern 236 thereby forming a complimentary weave pattern, as shown in FIG. 11.

In operation, tension can be applied to both first and second ends 224, 232 until the corresponding loops 238, 238′ are reduced to the desired size and/or load. At this point, the tension applied by the loops and the respective ends can cause the width reduction and constricting forces discussed above that, along with the weave patterns, can thereby lock the loops 238, 238′ relative to the central weave configurations. In addition, the portions of graft 184 associated with the first and second ends that form the weave patterns in this configuration can be contiguous to each other thereby causing additional friction and resistance to relative movement under tensile load.

With additional reference to FIGS. 12A-12B, an arrangement 270 for retaining or securing first end 224 of suture or graft 184 of adjustable loop construction 180 is provided. The arrangement 270 can include an aperture or slot 274 through each layer of the pleated configuration 192, as shown in FIG. 12A. The slot 274 can be formed parallel to a longitudinal axis of the graft 184 as shown, or in another orientation such as perpendicular thereto. A portion of the graft 184 adjacent a first side 278 of slot 274 can be moved away from slot 274 in a first direction 282 and a portion of the graft 184 on a second opposite side 284 of the slot 274 can be moved away in a second direction 286 opposite the first direction 282 thereby forming an opening 290. First end 224 can then be routed through opening 290 where the pleated configuration 192 can slightly expand against the opening and thereby assist in securing and retaining first end 224 in the pleated configuration 192, as shown in FIG. 12B. Passing first end 224 through opening 290 as discussed above can prevent the pleated configuration 192 at first end 224 from unfolding or separating.

It should be appreciated that pleated configuration 192 of suture or graft 184 can also be used to form the self-locking adjustable loop constructions 10, 10A, 10B and 80 discussed above with reference to FIGS. 2-6.

Turning now to FIGS. 13-14B, a forming device, such as a die 300, is provided and can be used for forming graft 184 in the pleated configuration 192 discussed above with reference to FIGS. 10 and 11. Graft 184, in the non-pleated form shown generally in FIG. 13, can be placed in die 300 and translated axially relative to the die to form the pleated configuration 192. Die 300 can include a similar construction to die 124 where a plurality of projections 304 and 308 protrude from respective first and second members 312 and 316, as shown in FIG. 14A. Upon closing the die 300, the projections 304, 308 can intermesh to shape the graft 184 placed therebetween into the pleated configuration 192, as shown in FIG. 14B.

The projections 304, 308 can be configured such that when they intermesh, there is enough clearance between the projections such that the graft 184 can be translated axially relative to die 300. Translation of graft 184 relative to die 300 can form the pleated configuration 192 along a longitudinal length of the graft 184 that is longer than a corresponding length of the die 300, as shown in FIG. 14B. In this manner, a relatively small and portable die 300 is provided that can be used intraoperatively to form a graft into the pleated configuration 192 for use in the self-locking adjustable loop constructions 180, 180A discussed above, as well as in adjustable loop constructions 10, 10A and 10B. The members 312, 316 of die 300 can also be coupled to or integrally formed with a movement device, such as forceps 168 to aid in opening and closing the die 300, as discussed above with reference to die 124 and FIG. 9.

The adjustable loop constructions described herein can be used in various surgical procedures to affect closure, secure a graft to soft tissue or bone, or in a ligament repair procedure, such as an ACL repair procedure. In an exemplary ligament repair procedure, for example, the single or double loop constructions disclosed herein can be used to secure a natural or artificial ACL to a fixation member, as disclosed in the above cases incorporated herein by reference. Further, the adjustable loop construction 180 formed from graft 184 can act as an ACL replacement in either the single or double loop configuration. Each of the adjustable loop constructions described herein can also serve to draw an ACL component up through a tibial tunnel and into a femoral tunnel, as well as adjust a tension of the ACL component.

While one or more specific examples have been described and illustrated, it will be understood by those skilled in the art that various changes may be made and equivalence may be substituted for elements thereof without departing from the scope of the present teachings as defined in the claims. Furthermore, the mixing and matching of features, elements and/or functions between various examples may be expressly contemplated herein so that one skilled in the art would appreciate from the present teachings that features, elements and/or functions of one example may be incorporated into another example as appropriate, unless described otherwise above. Moreover, many modifications may be made to adapt a particular situation or material to the present teachings without departing from the essential scope thereof. 

1.-20. (canceled)
 21. A method of forming an adjustable suture construct, comprising: providing or obtaining a suture that includes a body located between a first end and a second end of the suture; passing the first end of the suture fully through the body at a first location along the body and in a direction at the first location other than parallel to a longitudinal axis of the body at the first location so as to form an adjustable loop; and passing, after forming the adjustable loop, the first end of the suture fully back through the body at a second location along the body and in a direction at the second location other than parallel to a longitudinal axis of the body at the second location, the second location spaced apart from the first location along the body and also spaced apart from the adjustable loop, wherein a section of the body extending from the first location to the second location forms part of an accordion configuration that includes a first suture leg portion, a second suture leg portion, and a connecting portion that connects the first suture leg portion to the second suture leg portion.
 22. The method of claim 21, wherein the body includes a flat suture section.
 23. The method of claim 22, wherein the flat suture section comprises a braided suture.
 24. The method of claim 21 further comprising coupling an anchor member to the suture.
 25. The method of claim 21, wherein the body includes a hollow core suture section.
 26. The method of claim 21, wherein the direction at the first location is perpendicular to the longitudinal axis of the body at the first location.
 27. The method of claim 21 further comprising coupling a graft material to the suture.
 28. A method of forming an adjustable suture construct, comprising: providing or obtaining a suture that includes a body located between a first end and a second end of the suture; arranging the body in an accordion configuration that includes multiple suture legs, the multiple suture legs including at least a first suture leg and a second suture leg, the first suture leg adjacent the second suture leg within the accordion configuration, the accordion configuration further including a connecting portion that connects the first suture leg to the second suture leg; passing the first end of the suture fully through the body at a first location along the first suture leg and in a direction at the first location other than parallel to a longitudinal axis of the first suture leg at the first location so as to form an adjustable loop that is spaced apart from the second suture leg within the adjustable suture construct; and passing, after forming the adjustable loop, the first end of the suture fully back through the body at a second location along the second suture leg.
 29. The method of claim 28, wherein the body includes a flat suture section.
 30. The method of claim 29, wherein the flat suture section comprises a braided suture.
 31. The method of claim 28 further comprising coupling an anchor member to the suture.
 32. The method of claim 28, wherein the body includes a hollow core suture section.
 33. The method of claim 28, wherein the first end of the suture is passed fully back through the body at the second location in a direction at the second location other than parallel to a longitudinal axis of the second suture leg at the second location.
 34. The method of claim 28, wherein the direction at the first location is perpendicular to the longitudinal axis of the first suture leg at the first location.
 35. The method of claim 28 further comprising coupling a graft material to the suture.
 36. A method of forming an adjustable suture construct, comprising: providing or obtaining a suture that includes a flat-shaped body located between a first end and a second end of the suture; passing the first end of the suture fully through the flat-shaped body at a first location along the flat-shaped body so as to form an adjustable loop; passing, after forming the adjustable loop, the first end of the suture fully back through the flat-shaped body at a second location along the flat-shaped body, the second location spaced apart from the first location along the flat-shaped body and also spaced apart from the adjustable loop; and coupling the suture to a bone fixation member.
 37. The method of claim 36, wherein the flat-shaped body includes a first suture leg portion that extends away from the first location and connects via a connecting portion to a second suture leg portion that extends away from the second location.
 38. The method of claim 36, wherein the first end of the suture is passed fully through the flat-shaped body at the first location in a direction at the first location other than parallel to a longitudinal axis of the body at the first location.
 39. The method of claim 38, wherein the first end of the suture is passed fully back through the flat-shaped body at the second location in a direction at the second location other than parallel to a longitudinal axis of the body at the second location.
 40. The method of claim 36, wherein the flat-shaped body includes a braided suture.
 41. The method of claim 36 further comprising coupling a graft material to the suture. 